Diagnosis: Left knee patella fracture

Treatment: Physical Therapy Services (97140)

The insurer denied coverage for Physical Therapy Services (97140). The denial was upheld.

This patient is a male who was diagnosed with a left knee patella fracture after a fall in late-2018. The patient was initially non-weight bearing for approximately 4 weeks and was then advanced to weight bearing activity. The patient began physical therapy treatment in early-2019. The documentation detailed on a specified date, which is the date in question, that the patient was seen for the 15th visit of therapy. The patient reported ongoing improvement. The patient consulted a physical therapist for treatment for his injury. A 12 week treatment plan was implemented that included therapeutic exercises, therapeutic activities, gait training, neuromuscular rehabilitation, manual therapy, massage, patient education, electrical stimulation, ultrasound, phonophoresis, cryotherapy, and hot packs. The patient was treated with manual therapy as well as neuromuscular re-education and therapeutic exercise. The patient continued with treatment. The physical therapy progress note indicated that as of a specified date in early-2019, the patient was independent with home exercise plan (HEP). Continued improvement in pain and function was reported. However, this appears to be maintenance care as the pain is waxing and waning.

The documentation does not support the requested manual therapy on a specified date was medically necessary for this patient. There are no objective findings demonstrating improved range of motion (ROM) with the manual therapy. Uphold denial.

Based on the above, the medical necessity for the Physical Therapy Services (97140) is not substantiated. The insurer's denial is upheld.